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Optimizing Care Transitions Across the Continuum
Session #308, February 15, 2019
Tori Chestnut – Director, Care Transitions & Navigations
Jim Shull - Lead Healthcare Business Intelligence Analyst
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Tori Chestnut, MSN, MBA, RN
Jim Shull, BS
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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• Common Definitions
• Background/History
• Current State
• Outcomes
– Quality
– Financial
• Challenges
• Future Strategies/Recommendations
Agenda
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• Recognize the impact a care transition strategy has on patient
outcomes
• Identify how improving EHR efficiencies positively impacts staff
productivity
• Describe the financial impact of a centralized model on the
management of care transitions
Learning Objectives
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Facilities
• 8 Campuses
• 3 Institutes
• 1 Children’s Hospital
• 160+ Physician Practices
• 17 Community Clinics
• 25 Health Centers
• 18 ExpressCARE Locations
• 1 Children’s ExpressCARE
• 45 Rehab Locations
• 81 Testing and Imaging
Locations
Staff
• 18,000+ Employees
• 2,005 Physicians
• 834 Advanced Practice
Clinicians
• 4,208 Registered Nurses
Utilization
• 69,346 Acute Admissions
• 274,879 ED Visits
• 1,838 Acute Care Beds
Who We Are
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A Complete Health Network
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Integrated Care Coordination
Inpatient Care
Management
Responsible for the coordination of
care and discharge planning for
patients in the acute care setting.
Care Transitions &
Navigation
Responsible for patient
experiencing a transition from
inpatient to outpatient settings.
Hands patients off to ambulatory
care management teams.
Ambulatory Care
Management
Embedded in primary care
practices
Involves interdisciplinary teams
who work with patients longer
term.
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Transitional Care Management (TCM) Billing Codes
Definitions
Interactive Contact
• Attempts to reach
patient/caregiver
within 2 business
days of discharge
• Can be
telephonic, via e-
mail, or face-to-
face
Non-Face-to-Face
Services
• Review of
discharge
information
• Coordination of
care
• Communication
with community
agencies/services
Face-to-Face Visit
• Needs to occur
within 7 or 14
calendar days of
discharge
• Medical decision
making of
moderate or high
complexity by
billing provider
Additional
Information
• Can only bill once
every 30 days
• ED discharges
are excluded
• Not applicable if
patient receiving
hospice, home
health, or CCM in
same 30-day
period
Transitional Care Management Services. Center for Medicare and Medicaid Services website.
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Program History
2012
LVHN
implemented
TOC process
2015
Centralization
of Resources
2017
Optimization
of Technology
2018
Program
Expansion
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• Centralization of work has:
– Improved staff productivity
– Increased call compliance across the entity
– Shown a positive financial return
– Decreased ED utilization
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Program History
1. In a comparison of 1 group who received TOC calls (n=10,943) to 1 group of patients who did not receive
a call (n=4,547), there was an 8.4% decrease in ED utilization using a difference of differences
methodology. (April 2016-April 2017).
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• Our current state involves:
– Transition of Care call to eligible patients
– Close collaboration with providers in inpatient and outpatient
settings
• Hospitalist groups
• Primary and specialty care outpatient practices
Current State
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• Staffing Mix
Current State
RN Care
Managers
• Adult patients with a risk score >/=
5 and all pediatric patients
Medical
Assistants
• Focus on adult patients with a risk
score between 0 and 4
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• Risk Scoring
– Patients assigned risk score ranging from 0-8
– Moving to using the LACE+ Index
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Current State
1. Walraven, C., Wong, J., & Forster, A.J. (2012). LACE+ index: Extension of a validated index to predict early death or urgent
readmission after hospital discharge using administrative data. Open Medicine, 6 (3), e80-e90.
• Readmission within previous 180 days
+3
• Medicare/Medicaid/Self-Pay as primary insurance
+1
• High utilization (Admissions and ED visits)
+1
• Presence of 3 or more clinical indicators
+1
• Presence of 5 or more Chronic Conditions
+1
• Patient on 7 or more medications
+1
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• Which patients do we call?
– All patients attributed to our owned physician group
• Regardless of reason for admission or risk
• ~25,000 discharges annually
– All patients not attributed that are discharged from our NICU
or pediatric units OR that have the following diagnoses:
Current State
Heart Failure
COPD
Pneumonia
Sepsis
CABG
Total Joint
Replacements
Spine
Surgeries
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• What does the TOC call involve?
Current State
Assessment of current health status
Medication Reconciliation
Scheduling follow-up appointments
Ensuring right level of care
Linkage to community resources
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• How do we collaborate with providers across the continuum?
Current State
Inpatient
• Patient feedback
• Follow-up on identified discharge concerns
• Process Improvement
Outpatient
• Direct Scheduling
• Communication Pathways
• Pre-visit Planning
• Access
• Ongoing patient needs
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Outcomes
Key Performance
Indicators
Quality Financial
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Outcomes
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Outcomes
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Outcomes
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Outcomes
-31.9%
-40.3%
-50.0%
-40.0%
-30.0%
-20.0%
-10.0%
0.0%
10.0%
20.0%
Pre Post Percent Change
ED Utilization
Control TOC
Control Group:
n = 4,547 patients
TOC Group:
n = 10,943 patients
Timeframe:
April 2016 – 2017
Using :
Difference of Differences
8.4%
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• Financial Analysis – FY2018
Outcomes
Total Payment Balance Post-RVU Payment
Quantity of TCM Codes
Billed
+$1.3 million $642,950 7,994
Total Budgeted Expenses (FY2018): $380,000
ROI (Based on Total Payment): ~2.6:1
ROI (Based on Balance Post-RVU Payment): ~2:1
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Future Strategy/Recommendations
LEVERAGE
TECHNOLOGY
AUTOMATE AS
MUCH AS
POSSIBLE
CENTRALIZE
RESOURCES, IF
ABLE
COLLABORATE
WITH
LEADERSHIP TO
ENSURE
SCHEDULE
ACCESS
